Indications for Psychotropic Medication Use · some, withdrawal from alcohol, caffeine, nicotine or illicit drugs may require short term intervention. Reason Number 6 For sedation

Indications for Psychotropic Medication Use

The following table highlights common diagnostic and clinical indications for using psychotropic

medication. This may be used in conjunction with the attached general valid reasons for using

psychotropic medication as a broad tool for evaluating whether the use seems appropriate. This is not

meant to second-guess physicians and their order but as a point of team discussion.

When the justification is based more exclusively on signs and indications, greater care must be taken. For

example, more comprehensive baseline data and descriptive information must be documented and

regularly reviewed. The identified signs and symptoms must show clear evidence of decreased intensity

and severity to justify continued use.

The top row identifies the family of medication with the columns organized in descending order of valid

use by medication family. The table is not meant to be exhaustive, for example the entire family of

barbiturate medications is not included as they are rarely used with individuals with developmental

disabilities.

Neuroleptic

(Antipsychotic)

Antidepressant Mood

Stabilizer

Anti-anxiety Stimulant Antiparkinsonian

Diagnostic

indications (primary)

Psychosis,

schizophrenia,

schizoaffective

disorder,

delusional

disorder,

atypical

psychosis

Depressive

disorders

Bipolar mood

disorder,

depression,

schizo-

affective

disorder

Anxiety

disorders,

(Obsessive

compulsive,

post-

traumatic

stress, panic,

generalized)

Attention

deficit

disorder

Extrapyramidal

side effects

(secondary) Bipolar mood

disorder--acute

manic phase,

delusional

depression

Anxiety

disorders,

(Obsessive

compulsive,

post-

traumatic stress,

panic,

generalized)

Disorders of

attention

Mood

instability

Phobic

disorders,

akathesia,

tardive

dyskinesia

Depressive

disorders in

those who

are

medically

fragile,

narcolepsy

Signs and

indications

Disorganized

thought,

poor impulse

control

Bulimia,

narcotic craving

and withdrawal

depression,

chronic pain,

poor impulse

control

Poor impulse

control,

neuroleptic or

antidepressant

boost

Anxiety

symptoms:

aggression,

sleep

disturbance,

nightmares,

preoccupations

Disturbed sleep

Six valid reasons for using psychotropic medications

Reason Number 1

To treat a clearly diagnosed primary psychiatric illness:

Whether a potential recipient has a developmental disability or not, the criteria established in the

Diagnostic and Statistics Manual of Mental Disorders-IV-TR (DSM-IV-TR) or the International

Classifications of Diseases-10 (ICD-10), should be satisfied. At least the same depth and breadth of

evaluation must be exercised. This becomes increasingly more difficult with more significant

developmental disabilities and problems with speech, motor performance, cognitive ability and sensory

integration interfere with standardized testing and mental status exams. We expect this problem to

diminish as the Diagnostic Manual-Intellectual Disability (DM-ID) becomes more widely and effectively

used.

Reason Number 2

Medical conditions:

Some conditions may have associated secondary psychiatric features. Examples include specific types of

epilepsy, which may lead to a variety of seizures and problematic behaviors. For example, temporal lobe

seizures can appear as unusual behaviors. Use of appropriate psychotropic medication for this reason

should continue until the primary condition is treated and the symptoms resolve, or until it is clear that,

even with treatment, the psychiatric symptoms will continue. Long term medication therapy will

frequently be necessary in order to control symptoms. Examples of other medically indicated uses are

small doses of antipsychotic drugs prior to chemotherapy (for the antiemetic effect) or general

anesthesia.

Reason Number 3

Emotionally distressing, extreme behavior that interferes with important aspects of a person’s life:

This is perhaps the most contentious and challenging rationale. The risk of it being used as a “garbage

can” to justify medication for a variety of unpleasant, obnoxious, even hurtful behaviors that serve clear

functional means for an individual is inherent. This rationale should be accompanied by a comprehensive

assessment of the behavior that includes a functional assessment. If such assessment is unavailable or

yields unclear results—and intermediate intervention is necessary for safety or continued inclusion in

support efforts—short term psychotropic intervention may be considered. Use of medication in these

circumstances is most clearly indicated when the individual with developmental disabilities who presents

challenging behavior expresses a desire for the behavior to be controlled. When the person

cannot clearly communicate intentions, discerning the appropriateness of medication is more complicated.

Reason Number 4

For empirical reasons, to address severe dysfunction that has been resistant to other intervention:

There are times when the use of psychotropic medication should be considered when addressing a chronic

condition or characteristic (other than behavior) which significantly interferes with an individual’s social

functioning and quality of life, particularly when exhaustive habilitative, environmental and lifestyle

adaptation interventions have not provided relief. If effective, the smallest dose should be sought, with

occasional, systematic attempts to reduce or discontinue the medication. An example is using a mild

anxiolytic to ease acute difficulty with transitions experienced by an individual diagnosed with

Pervasive Developmental Disorder (PDD), even when an anxiety disorder diagnosis is not established.

Reason Number 5

To treat medication withdrawal or discontinuation symptoms:

There is a growing awareness that people may experience withdrawal difficulties from a variety of

psychotropic medications, although they may be markedly softened with gradual reductions. These

symptoms may include anxiety, agitation, unstable mood, self-stimulation, insomnia, expressiveness,

sexual expression, property destruction, and self-injury. Another instance would be when—upon

decreasing or discontinuing a psychotropic medication which masked severe tardive

dyskinesia symptoms—a return to a small dose or alternative drug may be required. For a

small group of individuals with developmental disabilities who exhibit chronic, severe self-injury,

withdrawal from endogenous endorphins may be a factor needing psychotropic medication intervention.

Endogenous endorphins are naturally occurring neurotransmitters which have a narcotic-like effect. For

some, withdrawal from alcohol, caffeine, nicotine or illicit drugs may require short term intervention.

Reason Number 6

For sedation during a medical procedure:

When the importance of a medical procedure is unquestioned and the procedure cannot be performed

without sedation, a psychotropic may be used for its sedating effect. For some individuals these medical

procedures may include dental work, diagnostic evaluations such as EEGs, EKGs, C-T scans or physical

exams. If used for this purpose, an adequate dose to accomplish the desired sedation must be sought

and balanced against the least potential side effects.

Cautions and Questionable Uses of Psychotropic Medication

Just as there are clear reasons to consider the use of psychotropic medications, there are also questionable

ones, many of which suggest misuse of the drug and, potentially, abuse of the individual with

developmental disabilities. We encourage the following to be considered even if one of the preceding

reasons seems to be met. The following is a list of questionable uses that can be prevented, avoided or

corrected. Subsequent chapters offer methods of support that reduce the likelihood that these

problems will occur.

Caution Number 1

No re-examination of the original decision to prescribe psychotropics:

When the initial rationale for prescribing a medication is not reexamined and when there is a lack of

evidence for the continued need for long-term use of psychotropic medication.

Caution Number 2

Inadequate assessment:

When psychotropic medication is prescribed without a thorough assessment and comprehensive reporting

to the prescribing physician.

Caution Number 3

Haphazard prescribing:

When psychotropic medications are prescribed in a reactive, haphazard manner, quickly discontinuing one

and substituting another.

Caution Number 4

Prescribing psychotropics for the convenience of caregivers:

When medication is used to make the individual more “manageable” for the convenience of individuals

who provide support to the person. The expectation that psychotropic medication can preclude outbursts

is unrealistic except at extremely high doses. In fact, using psychotropic medication may make life more

difficult for support providers as the individual changes in response to the drug. In many cases, moderate

doses of antipsychotic medications (or any dose of benzodiazepines) may interfere with the learning

processes that would enable the individual to change “unmanageable” behaviors.

Caution Number 5

Ignoring the message the person is attempting to communicate with behavior:

When medication is used to blunt a behavior without recognizing what the person intended to

communicate with the behavior.

Caution Number 6

Interpreting an understandable behavioral response as pathological:

When medications are used to treat the response to an empty life rather than addressing the empty life.

Many individuals with developmental disabilities who present challenging behavior are expressing

appropriate anger, fear, sadness, loneliness, frustration, and other unpleasant, powerful emotions in the

only way they know.

Caution number 7

Limiting autonomy:

When the effects of medication or the methods used to monitor them unduly limit the person’s autonomy.

When possible, the individual with a developmental disability must have a forum for expressing his/her

reaction to the psychotropic medication. Do they feel better or worse? Does taking a particular medication

enhance or detract from their notion of how they want to live?

Caution Number 8

Exceeding therapeutic range:

When medication dosages are increased, beyond the therapeutic range, in response to a conclusion that a

smaller amount didn’t work (more medicine isn’t necessarily better). The exception is when the treatment

plan calls for an initial low dose with the intention of periodic, potential increases in dosage based on

response.

Caution Number 9

Caregivers lacking knowledge:

When the people empowered to administer and/or monitor the effective use of the medication lack the

information about the person, the prescribed medication, and the reason for using it, as well as the

necessary training to competently administer medication and monitor its effect.

Caution Number 10

Lax administration of prn medication:

When medications prescribed on a prn (as needed) basis are administered by various people with

minimal training working in different environments without adequate training, supervision,

monitoring, or communication among various staff and provider agencies.

Caution Number 11

Using medication to mask abuse:

When medications are used to mask signs of abuse, effectively silencing legitimate complaints.

Emerging research indicates that 95% of individuals with mild or moderate cognitive disabilities

who present aggressive behavior have been physically or sexually abused by peers, family

members or caregivers.

Caution Number 12

Using medications as a substitute for appropriate support:

When medications are used as a substitute rather than a complementary adjunct to thorough, meaningful

habilitative programs and positive behavioral support.

Commonly Prescribed Psychotropic Medication

This is not a comprehensive listing of either psychotropic medication or side effects.

Antipsychotic medication

Medication Type Generic Name Trade

Name

Usual

Adult Dose

Range

(mg/day)*

Prescribing

limits

(mg/day)**

Side Effects

Typical

Antipsychotic

chlorpromazine

(CPZ)

Thorazine 100-800 1000 Very sedating, blood pressure drop,

increased heart rate, sun sensitivity,

heat stroke, anticholinergic effects,

cataracts, weight gain, , neuroleptic

malignant syndrome, lower seizure

threshold, tardive dyskinesia

fluphenazine Prolixin 2-20 40 Extrapyramidal side effects,

decreased anticholinergic effects

haloperidol Haldol 2-20

100 Extrapyramidal side effects,

decreased anticholinergic effects

loxapine Loxitane 10-80 250 Same as CPZ, mildly less sedating

mesoredazine Serentil 50-400 500 Similar to CPZ, mildly less sedating,

low extrapyramidal effects

molindone Moban 10-100 225 Extrapyramidal side effects,

decreased anticholinergic effects

perphenazine Trilafon 10-64 64 Same as CPZ

prochlorperazine Comazol,

Compazine

15-150 150 Extrapyramidal side effects, less

sedating, low incidence

anticholinergic effects.

thioridizine Mellaril 100-800 800 Same as CPZ add retinal pig-

mentation above 800 mg.

thiothixene Navane 4-40 60 Extrapyramidal side effects,

decreased anticholinergic effects

trifluperazine Stelazine 5-40 80 Moderately sedating, moderate

extrapyramidal side effects,

decreased anticholinergic effects

*The range found necessary to manage symptoms of psychosis determines dose range.

** Prescribing limits are often determined by the manufacturer and represent the maximum daily dose

administered to manage severe symptoms of psychosis, usually in a hospital setting.

Incidence of side effects

Medication Type Generic Name Trade

Name

Sedation EPS Anticholinergic

Typical

Antipsychotic

chlorpromazine

(CPZ)

Thorazine ++++ +++ +++

fluphenazine Prolixin + ++++ +

haloperidol Haldol + ++++ +

loxapine Loxitane +++ +++ ++

mesoredazine Serentil +++ + ++

molindone Moban + +++ ++

perphenazine Trilafon ++ +++ ++

prochlorperazine Comazol,

Compazine

++ ++++ +

thioridizine Mellaril ++++ +++ ++++

thiothixene Navane + ++++ ++

trifluperazine Stelazine ++ +++ ++

+ a very low incidence, ++ a low incidence, +++ a moderate incidence, and ++++ a high incidence

Atypical

Antipsychotic

Generic

Name

Trade

Name

Usual

Adult

Dose

Range

(mg/day)*

Prescribing

limits

(mg/day)**

Side Effects

aripiprazole Abilify 10-30 30 Nausea, vomiting, constipation,

headache, dizziness, an inner

sense of restlessness or need to

move (akathisia), anxiety,

insomnia, and restlessness

clozapine Clozaril 50-600 900 Agranulocytosis, sedation,

anticholinergic effects, increased

blood pressure, orthostatic blood

pressure drop, sun sensitivity,

drooling, sweating, weight gain,

nausea, headaches, lower seizure

threshold

olanzapine Zyprexa 10-20 20 Drowsiness, dizziness, dry

mouth, agitation, orthostatic

blood pressure drop, weight gain,

quetiapine Seroquel 250-600 800 Sedation, orthostatic blood

pressure drop, increased heart

rate, weight gain,

risperidone Risperdal 2-6 16 Orthostatic blood

pressure drop, insomnia, weight

gain, extrapyramidal side effects

above 6 mg, akathisia, anxiety

ziprasidone Geodon 40-160 200 Sleepiness, abnormal muscle

movements (e.g., tremors,

shuffling, and uncontrolled

muscle movements), dizziness,

restlessness

*The range found necessary to manage symptoms of psychosis determines dose range.

** Prescribing limits are often determined by the manufacturer and represent the maximum daily dose

administered to manage severe symptoms of psychosis, usually in a hospital setting.

Incidence of side effects

Atypical

Antipsychotic

Generic

Name

Trade

Name

Sedation EPS Anticholinergic

aripiprazole Abilify ++ + +

clozapine Clozaril ++++ + ++++

olanzapine Zyprexa ++ ++ ++

quetiapine Seroquel ++ + +

risperidone Risperdal + ++ +

ziprasidone Geodon ++ ++ +

+ a very low incidence, ++ a low incidence, +++ a moderate incidence, and ++++ a high incidence

Antidepressant medications.

Antidepressants

(cyclical)

Generic name Trade name Initial adult

dose

(Prescribing

limit)

mg/day

Side effects Other

information

amitriptyline Elavil, Endep,

others

50-100

(300)

Overdose potential, sedation,

blood pressure drop,

anticholinergic effects (see

CPZ), cardiac arrhythmias,

weight gain, decreased libido,

impotence, lower seizure

threshold, nightmares

Increase effect

of alcohol,

abrupt

withdrawal can

produce

problems

amoxapine Ascendin 100+150

(600)

Same as above,

extrapyramidal

side effects, tardive dyskinesia

Contains

Loxitane

chlomipramine Anafranil 75

(300)

Same as above Good results

with obsessive

compulsive

disorder

desipramine Norpramine 100-200

(300)

Same as above SSRI boost

doxepin Sinequan 75

(300)

Same as above Popular with

substance

abusers

imipramine Tofranil,

Norfranil,

others

75-200

(300)

Same as above Good results

with panic

disorder,

bedwetting

nortriptyline Pamelor,

Aventyl

75-100

(150)

Fewer, but same as above

Antidepressants

(Second

generation)

*SSRI-Selective Serotonin

Reuptake Inhibitor

bupropion Wellbutrin 150

(400)

Excess stimulation, headache,

insomnia, anxiety, nausea

High incidence

of seizures in

those with

anorexia

Citalopram* Celexa 20

(60)

Same as with other SSRI's,

particularly reduced libido or

impotence, but

usually less apparent

Considered by

some to be a

"weaker"

SSRI

Escitalopram* Lexapro 10

(20)

Similar to Celexa

Fluoxetine* Prozac 20

(80)

Agitation, insomnia, weight

loss, sexual dysfunction

(decreased libido, difficulty

with orgasm), sedation,

headaches, Serotonin

Syndrome (shivering,

incoordination, fever, muscle

rigidity, confusion, sweating,

diarrhea)

Can interfere

with how many

other

medications are

metabolized

Fluvoxamine* Luvox 50

(300)

Same as above although more

sedating and less agitating

Good results

with

obsessive

compulsive

disorder

maprotiline Ludiomil 25-75

(225)

Same as above, lower seizure

Threshold, lethal overdose

potential

Rarely pre-

scribed

mirtazapine Remeron 15

(45)

Sedation, weight gain, dry

mouth, constipation, dizziness,

Seems to help

with anxiety

and

sleep problems

in depression

nefazodone Serzone 200

(600)

Similar to Trazodone without

priapism, some sedation,

anticholinergic effects

Better tolerated

by most

Paroxetine* Paxil 20

(50)

Same as above with less sleep

disturbance

Lowest cost.

Recent FDA

approved for

anxiety

disorders

Sertraline* Zoloft 50

(200)

Lowest side effect profile of

SSRI's, although may see

effects noted above

Shorter half-

life

trazodone Desyrel 150

(600)

Very sedating, ortho-

static blood pressure drop,

nausea, headache, priapism

Very short

half-life

venlafaxine Effexor 75

(375)

Sedation, increased blood

pressure, nausea, constipation,

decreased libido

Affects neuro-

transmitter

norepinephrine

in addition to

serotonin

Incidence of side effects

Antidepressants

(cyclical)

Generic name Trade name Sedation Anticholi-

nergic

Orthostatic

Hypotension

Cardiac

Arrhythmia

Seizures

amitriptyline Elavil,

Endep,

others

++++ ++++ +++ +++ +++

amoxapine Ascendin ++ +++ ++ ++ +++

chlomipramine Anafranil ++++ ++++ ++ +++ ++++

desipramine Norpramine ++ ++ ++ ++ ++

doxepin Sinequan ++++ +++ ++ ++ +++

imipramine Tofranil,

Norfranil,

others

+++ +++ ++++ +++ +++

nortriptyline Pamelor,

Aventyl

++ ++ + ++ ++

Antidepressants

(Second

generation)

bupropion Wellbutrin 0 + 0 + ++++

citalopram Celexa + 0 0 0 ++

escitalopram Lexapro + 0 0 0 ++

fluoxetine Prozac 0 0 0 0 ++

fluvoxamine Luvox 0 0 0 0 ++

maprotiline Ludiomil +++ +++ ++ ++ ++++

mirtazapine Remeron ++ + ++ + +

nefazodone Serzone +++ 0 +++ + ++

paroxetine Paxil + + 0 0 ++

sertraline Zoloft 0 0 0 0 ++

trazodone Desyrel ++++ 0 +++ + ++

venlafaxine Effexor + + 0 + ++

Mood stabilizing medications

Lithium has long been the gold standard for treating bipolar disorder and for mood regulation with manic

features. It presents a unique challenge as it is not metabolized with drug elimination occurring almost

exclusively through excretion in the urine. As a result, there is a danger of accumulation in the body to

toxic levels that may include seizures, respiratory complications, coma, and death.

Mood stabilizers

carbamazepine Tegretol 200-1800 Decreased white blood cell

production, sedation, clumsiness,

dizziness, tremors, abnormal

cardiac conduction, decreased

thyroid hormones, rashes,

temporary liver enzyme

increases

Significant side

effects usually occur in first six

months of use

gabapentin Neurontin 1200-3600 Sedation, dizziness, tremors,

fatigue, headaches, blurred or

double vision, clumsiness,

weight gain, constipation

Less well

established as mood

stabilizer

lamotrigine Lamictal 400 Rash which may lead to a life

threatening condition,

clumsiness, headaches, nausea,

dizziness, severe sore throat

Particularly

effective for

rapid cycling or hard to treat

mood disorders (anecdotal

reporting)

lithium Eskalith,

Lithobid,

Lithonate

300-1800 Nausea, vomiting, diarrhea,

increased thirst, polyuria, acne,

weight gain, tremors, mild

decreased cognition,

hypothyroidrism, fatigue

Toxic effects: decreased

appetite, confusion, muscle

twitching, slurred speech, eye

jerking, increased reflexes,

stupor, coma

valproic acid Depakene,

Depakote

750-3000 Nausea, vomiting, significant

weight gain, hair loss, sedation,

tremors, decreased white blood

cell production, liver toxicity in

children

Usually well

tolerated

verapamil Calan, Isoptin 80-160 TID Decreased heart rate and

blood pressure, dizziness,

headaches, nausea, diarrhea or

constipation, decreased energy

Calcium channel

blocker originally used to treat

angina

Antianxiety medications

As noted above, many SSRI and SNRI antidepressants are becoming the first choice in addressing the

symptoms of anxiety. The following are examples of traditional drugs usually classified as having

sedative-hypnotic capacities and continue to be used as antianxiety agents.

Anti-anxiety

(benzodiazepines)

Generic Name Trade

Name

Initial

Adult Dose

(mg/day)

Side Effects Other

Information

alprazolam Xanax .25-.5 TID Sedation, drowsiness,

decreased cognition,

decreased memory,

disinhibition, decreased

respiration, potential for

addiction, withdrawal

syndrome (anxiety,

irritability, restlessness,

tremors, weakness, fatigue,

insomnia), rebound anxiety

Medium

absorption,

short acting

Antipanic and

mood

stabilizing

properties

chlordiazepoxide Librium 5-25 QID Same as above Medium

absorption,

long acting

clonazepam Klonopin .25-.5 BID Same as above Rapid

absorption,

long acting,

Antipanic and

mood

stabilizing

properties

clorazepate Tranxene 7.5-15 BID

to QID

Same as above Rapid

absorption,

long acting

diazepam Valium 2-10 BID to

QID

Same as above Rapid

absorption,

long acting

lorazepam Ativan 1-3 BID or

TID

Same as above Medium

absorption,

short acting

oxazepam Serax 10-30 TID

or QID

Same as above Slow

absorption,

short acting

prazepam Centrax 20-60 Same as above Slow

absorption,

long acting

temazepam Restoril 7.5-30 Same as above Medium

absorption,

short acting

Antianxiety

(non-

benzodiazepines)

buspirone Buspar 15-60 Headache, dizziness, nausea,

dry mouth

2-4 weeks

before

effective,

rarely effective

with past

benzodiazepine

use, question

about

effectiveness

with

individuals

with

developmental

disabilities

Alpha-adrenergic

agonist

clonidine Catapres .05-.3 mg Decreased blood pressure,

dizziness, sedation, dry

mouth, constipation, fluid

retention, depression,

nightmares, rashes

Anecdotal evi-

dence of

benefit to those

with post-

traumatic

stress disorder,

withdrawal

from opiates

and cocaine

Stimulant medication

amphetamine Dexedrine 5-90 mg Excess stimulation, anxiety,

irritability, insomnia, decreased

appetite, increased blood pressure

and heart rate, sweating, glaucoma,

seizures, movement disorders,

psychosis, paranoia

About 75% of

all stimulants are given to

children in the US,

Street value as "speed"

amphetamine

sulfate

Adderall 5-80 mg Nervousness, anxiety, insomnia,

nausea, diarrhea, rashes, increased

pulse and blood pressure

methylphenidate Ritalin May-80 Same as above Medication of

choice to treat disorders

of attention in children

pemoline Cylert 18-112.5 mg Same as above

Side effect medications

Anticholinergic benztropine Cogentin 1-2 Anticholinergic syndrome

(dry mouth, blurred vision,

increased heart rate, flushed

skin, constipation, delirium,

More often used

with high

potency

neuroleptics

biperiden Akineton 6-8 Same as above

procyclidine Kemadrin 7.5-15 Same as above

trihexyphenidyl Artane 6-10 Same as above

Antihistamine diphenhydramine Benadryl 75-200 Same as above

Dopamine

agonist

amantadine Symmetral 100-400 Nausea, dizziness, anxiety,

irritability, depression,

insomnia, clumsiness, tremors,

seizures, impaired cognition

Not as effective

as

anticholinergics

Antioxidant vitamin E 400-1200 Fatigue, weakness, nausea,

headache, blurred vision,

diarrhea

Effectiveness

not established